COVID-19 in pregnancy: evidence from LMICs
Authors: Maria Laura Costa, Charles M Charles
Journal: The Lancet Global Health (2022)

We read with great interest the study by Leonard Mndala and colleagues published in The Lancet Global Health.1Mndala L Monk EJM Phiri D et al.Comparison of maternal and neonatal outcomes of COVID-19 before and after SARS-CoV-2 omicron emergence in maternity facilities in Malawi (MATSurvey): data from a national maternal surveillance platform.Lancet Glob Health. 2022; (published online Sept 22.)https://doi.org/10.1016/S2214-109X(22)00359-XSummary Full Text Full Text PDF PubMed Scopus (2) Google Scholar They report maternal and neonatal outcomes of COVID-19 in 261 pregnant and recently pregnant women (up to 42 days post-delivery) in Malawi during the omicron wave, compared with the preceding waves of beta and delta SARS-CoV-2 variants. The authors found that a severe maternal outcome and maternal death were less common during the omicron wave than during the beta and delta waves (p≤0·05). Shortness of breath was the only symptom associated with poor maternal outcomes (p<0·0001), and was less commonly reported in the omicron wave than in the beta and delta waves (p<0·001). There is an urgency to acknowledge that data regarding the burden of COVID-19 on maternal and perinatal outcomes in sub-Saharan Africa and other areas in low-income and middle-income countries (LMICs) are under-represented in the medical literature. Structured surveillance systems on health outcomes allow for a fast response and uptake of data to support policymakers, and these are mostly implemented in high-income settings. For example, during the early period of the pandemic, the US Centers for Disease Control and Prevention reported increased morbidity with hospitalisation, intensive care unit (ICU) admissions, and mechanical ventilation among pregnant or postpartum women, but not increased mortality (adjusted odds ratio 0·9 [95% CI 0·5–1·5]).2Ellington S Strid P Tong VT et al.Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status—United States, January 22–June 7, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 769-775Crossref PubMed Scopus (34) Google Scholar As the pandemic evolved, data showed that symptomatic pregnant and postpartum women with confirmed SARS-CoV-2 infection were at greater risk of ICU admission (3·0 [2·6–3·4]), extracorporeal membrane oxygenation (2·4 [1·5–4·0]), and death (1·7 [1·2–2·4]), than were their non-pregnant counterparts.3Zambrano LD Ellington S Strid P et al.Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status—United States, January 22–October 3, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1641-1647Crossref PubMed Google Scholar Moreover, data from a living systematic review, including 435 studies, also reported greater risk of severe maternal morbidity (invasive ventilation: odds ratio 2·41 [2·13 to 2·71]), mortality (6·09 [1·82 to 20·38]), stillbirth (1·81 [1·38 to 2·37]) and neonatal death (2·35 [1·16 to 4·76]) than did non-pregnant women with SARS-CoV-2 infection.4Allotey J Stallings E Bonet M et al.Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.BMJ. 2020; 370m3320PubMed Google Scholar Most of the included studies were from high-income countries. Health emergencies are known to shed light on underlying weaknesses in the health system, worsening delays in medical care and revealing inequities within a population. Most countries in sub-Saharan Africa and other LMICs have ineffective epidemiological surveillance systems and, therefore, are underrepresented when considering the impact of a pandemic on maternal and perinatal health. Even when surveillance is adequately implemented, it rarely translates into timely public health interventions. Brazil, for example—with reliable data from the national surveillance system on severe respiratory syndrome—reported clear inequities and delays in medical care during the COVID-19 pandemic, given that 22·6% of women died without having been admitted to an ICU and 14·6% without ventilatory support early in the pandemic.5Takemoto MLS Menezes MO Andreucci CB et al.The tragedy of COVID-19 in Brazil: 124 maternal deaths and counting.Int J Gynaecol Obstet. 2020; 151: 154-156Crossref PubMed Scopus (109) Google Scholar Mndala and colleagues' analyses were made possible by the previously implemented national maternal surveillance platform in Malawi (MATSurvey). Another multi-institutional effort in Latin America was the use of the Perinatal Information System (SIP) from the Latin American Center for Perinatology, Women and Reproductive Health, which allowed the uptake of regional data on eight countries, presenting 447 maternal deaths.6Maza-Arnedo F Paternina-Caicedo A Sosa CG et al.Maternal mortality linked to COVID-19 in Latin America: results from a multi-country collaborative database of 447 deaths.Lancet Reg Health Am. 2022; 12100269PubMed Google Scholar In keeping with the MATSurvery data, dyspnoea was the most frequent symptom at admission, and was present in 73% of women who died. Other research initiatives in LMICs implemented before the COVID-19 pandemic also enabled the quick organisation of data collection. In Brazil, the Network of Studies on Reproductive and Perinatal Health, which was implemented over 10 years ago initially for the surveillance of maternal morbidity, provided baseline data for the multicentre REBRACO study (named to denote the Brazilian network of COVID-19 during pregnancy). Data from REBRACO showed that the availability of tests for SARS-CoV-2 and outcomes varied throughout the first year of the pandemic (before the dominance of gamma as a variant-of-concern), with worse outcomes in the initial 4 months.7Souza RT Cecatti JG Pacagnella RC et al.The COVID-19 pandemic in Brazilian pregnant and postpartum women: results from the REBRACO prospective cohort study.Sci Rep. 2022; 1211758Crossref Scopus (2) Google Scholar This finding is certainly true for other settings in LMICs. REBRACO joined an ongoing initiative of WHO to use a generic protocol for the reporting of findings on COVID-19 during pregnancy, including in several LMICs in Africa, Latin America, and Asia, with an expected sample size of more than 20 000 women.8WHOGeneric protocol. A prospective cohort study investigating maternal, pregnancy and neonatal outcomes for women and neonates infected with SARS-CoV-2.https://www.who.int/docs/default-source/coronaviruse/2020-1-pregnancy-and-neonates-study-2020-12-02-en.pdf?sfvrsn=56fbc0c0_1Date: Dec 2, 2020Date accessed: September 15, 2022Google Scholar The findings reported by Mndala and colleagues, regardless of the small sample size of 261 women, include 28 health-care facilities and contribute substantially to elucidating the burden of different SARS-CoV-2 variants and variants-of-concern on maternal and perinatal outcomes. Most notably, by comparing the dominant time periods of different variants-of-concern, they showed that omicron was associated with better maternal and perinatal outcomes. These findings are similar to those of other studies.10Adhikari EH MacDonald L SoRelle JA Morse J Pruszynski J Spong CY COVID-19 cases and disease severity in pregnancy and neonatal positivity associated with delta (B.1.617.2) and omicron (B.1.1.529) variant predominance.JAMA. 2022; 327: 1500-1502Crossref PubMed Scopus (14) Google Scholar There is great disparity in vaccine coverage, especially among countries in Africa, with scarce data available during pregnancy. Overall vaccine coverage varies from the 3·2% reported in Malawi and 4·6% in Nigeria, to 11·6% in Zambia and 30·0% in South Africa, considering data up to March, 2022. Data from Brazil, in the same period, showed that 40·3% of pregnant and postpartum women were fully vaccinated; among these women, those with COVID-19 infection had a 50% reduction in dyspnoea and ICU admission and an 80% reduction in intubation and maternal mortality when compared with their unvaccinated counterparts.9WHO regional office for AfricaAfrica COVID-19 vaccination dashboard.https://app.powerbi.com/view?r=eyJrIjoiOTI0ZDlhZWEtMjUxMC00ZDhhLWFjOTYtYjZlMGYzOWI4NGIwIiwidCI6ImY2MTBjMGI3LWJkMjQtNGIzOS04MTBiLTNkYzI4MGFmYjU5MCIsImMiOjh9Date: 2022Date accessed: September 15, 2022Google Scholar Therefore, there is evidence that vaccination reduces severe outcomes. The global progress in reducing maternal mortality in the past two decades is notable; however, the 2030 Sustainable Development Goal 3.1 target is far from being achieved, especially in LMICs. The COVID-19 pandemic has aggravated such numbers, drawing attention towards the challenge of prioritising health care. To implement measures to avoid preventable mortality in under-resourced settings, we need the data and we need action. We declare no competing interests. Comparison of maternal and neonatal outcomes of COVID-19 before and after SARS-CoV-2 omicron emergence in maternity facilities in Malawi (MATSurvey): data from a national maternal surveillance platformMaternal and neonatal outcomes from COVID-19 were less severe during the fourth wave of the SARS-CoV-2 pandemic in Malawi, during omicron dominance, than during the preceding beta and delta waves. Full-Text PDF Open Access